Ophthalmology Referral

Refer if any of the following signs/symptoms are present:

• Sensitivity to light, photophobia
• Pain (may be exacerbated by light)
• Unequally sized, sluggishly reactive, or fixed pupil
• Blurry vision (not related to excessive watery eyes)
• Ciliary flush - injection of deep episcleral vessels around cornea
  • Involves the limbus - border between sclera and cornea
  • Faint violet ring around cornea may also be seen
  • Associated with corneal inflammation, iridocyclitis, acute glaucoma (not conjunctivitis which spares the limbus)
• Allergic conjunctivitis refractory to ocular antihistamine/mast cell stabilizing agents (e.g. olopatadine)
• In ophthalmology, no steroid is considered “safe", therefore patients given ocular steroids should be monitored by an ophthalmologist due to risk of increased intraocular pressure, infection, and cataracts

Differential Diagnosis

• Allergic conditions are often accompanied by significant itch, whereas this is not very common in infection
• Allergic conjunctivitis principally affects the conjunctiva, whereas the principal target tissue in dry eye is the cornea

Disease	Clinical parameters	Signs/symptoms	Differential diagnosis
Seasonal allergic conjunctivitis (SAC) Perennial allergic conjunctivitis (PAC)	Sensitized individuals, AR Bilateral involvement Self-limiting	Ocular itching Tearing (watery discharge) Ocular chemosis, redness Often associated with rhinitis Not sight-threatening space	Infective conjunctivitis Preservative toxicity Conjunctivitis medicamentosa Dry eye AKC/VKC
Atopic keratoconjunctivitis (AKC)	Family/personal history of AD, allergic sensitization Teens, young adults (teens to 50 years) Bilateral involvement Chronic symptoms	"Atopic dermatitis of the eye" Severe ocular itching and burning Red flaking periocular skin Disease activity may parallel AD Mucoid discharge, photophobia Corneal erosions Scarring of conjunctiva Cataract (anterior) vs. steroids which typically cause posterior subcapsular cataracts Keratoconus Horner-Trantas dots White nodular bumps containing epithelial/eosinophilic debris around cornea Loss of eyelashes Sight-threatening space	Contact dermatitis Infective conjunctivitis Blepharitis Pemphigoid VKC/SAC/PAC/GPC
Vernal keratoconjunctivitis (VKC)	Associated with atopic disorders Peak incidence 3–20 years old, generally improves or resolves at puberty Males > female (2:1) Bilateral involvement Warm, dry climate, usually with onset in the summer Chronic symptoms Associated with AD (in 75%) and family history of atopy (66%)	Severe ocular itching Severe photophobia Ptosis of upper eyelid Copious thick, ropy discharge (containing eosinophils) Horner-Trantas dots White nodular bumps containing epithelial/eosinophilic debris around cornea Cobblestone papillary hypertrophy (upper lid) Corneal ulceration and scarring (shield ulcers) Sight-threatening space	Infective conjunctivitis Blepharitis AKC/SAC/PAC/GPC
Giant papillary conjunctivitis (GPC)	Foreign body in eye - contact lens users, ocular prostheses, sutures Extended wear soft > hard > soft contact lenses Sensitization not necessary but disease worse with concomitant AC Bilateral involvement Chronic symptoms	Mild ocular itching Mild mucoid discharge Giant papillae >0.3 mm of upper tarsal (inner eyelid) conjunctiva with flatter surface than VKC Contact lens intolerance Foreign body sensation Protein buildup on contact lens Not sight-threatening space	Infective conjunctivitis Preservative toxicity SAC/PAC/AKC/VKC
Dry eye syndrome (keratoconjunctivitis sicca)	Prevalence increases with age (especially >50 yo) Can be secondary to Sjogren's syndrome Associated with contact lens use, corneal surgery (including LASIK), diabetes, chronic use of eye medications (especially if they contain preservatives), some systemic medications (antihistamines, anticholinergics, estrogens, isotretinoin, selective serotonin receptor antagonists, amiodarone, nicotinic acid) May be diagnosed by non-opthalmologists, possibly noting the following on exam: Conjunctival injection (usually symmetric) Excessive tearing (may paradoxically be a sign of dry eye) Blepharitis (visible as erythematous or irritated eyelid edges) Malposition of the eyelids (inward or outward turning) Reduced blink rate Visual impairment	Dryness Red eyes General irritation Gritty, burning, and/or foreign body sensation Excessive tearing Light sensitivity Blurred vision
Drug-induced allergic conjunctivitis	Most commonly involved agents include: Beta blockers Alpha agonists Epinephrine derivatives Miotics (Pilocarpine) Neomycin Preservative (benzalkonium) hypersensitivity Alpha agonists and preservatives may also cause follicular conjunctivitis Prostaglandin analogues used for glaucoma (e.g. latanoprost, bimatoprost, travoprost) routinely cause conjunctival hyperemia (without pruritus) and increased eye lash growth
Hypersensitivity to Preservatives in Ocular Drugs	Mechanisms vary (Type I-IV, irritant) Most commonly reported preservatives: Benzalkonium chloride (quaternary ammonium class) Thimerosal (organomercurial derivative) Chlorhexidine (amidine) Chlorobutanol, phenylethanol (alcohols) Parabens
Other threatening eye conditions - refer Iritis Scleritis Episcleritis Acute glaucoma Herpes simplex keratitis and other forms of keratitis

Ocular contact dermatitis - via direct application of substances containing irritants/antigens and eye rubbing following manual contact with an antigen

• Symptoms can include rash over the eyelids, tearing, redness, itching, stinging/burning sensations, and a sensation of fullness in the eye when swelling is involved. The eyelid may appear thickened, red, and sometimes ulcerated. When the conjunctiva is involved, vasodilatation, chemosis, watery discharge, and sometimes papillae can be observed.
• Common allergens include topical drugs and antibiotics (anesthetics, neomycin, antivirals, pilocarpine, timolol), preservatives in ophthalmic solutions (thimersol, benzalkonium chloride, chlorobutanol, chlorhexidine, EDTA), cosmetics (eye and lip glosses containing waxes, fats, and dyes), perfumes, sunscreens containing PABA , fingernail products (containing formaldehyde resins and sulfonamide derivatives), hair products (dyes, permanent solutions), adhesives (false eyelashes), nickel (eyelash curlers and eyeglass frames), irritant plants (poison ivy, sumac, oak), latex (gloves), as well as soaps, detergents, bleach, and solvents.
• Patch testing is the most useful diagnostic tool

Treatment Approach

Basic Eye Care

• Avoid eye rubbing, which can trigger mast cell degranulation
• Use of artificial tears multiple time/day can wash out allergens
• Cool compresses can soothe itch
• Reduce or avoid contact lens use during exacerbation

Medications

Allergic Conjunctivitis Practice Parameter Draft (2011)

Seasonal/Perennial AC

• Avoidance of the specific allergen
• Treatment tailored to severity:
  • Mild to moderate AC
    • Dual-acting topical ocular medication (olopatadine, ketotifen, azelastine). The mast cell stabilizing component of these drugs benefits patients most if treatment is started before the height of symptom onset.
  • Severe AC
    • Combination therapy is recommended, may include topical medications (antihistamines, mast cell stabilizers, NSAIDs), and oral antihistamines
    • In extreme cases, the use of a topical corticosteroid four times a day should be considered. All patients receiving topical corticosteroid should have their intraocular pressure monitored.
• Allergen immunotherapy
• If patient wears contact lenses, recommend daily disposable lenses to avoid accumulation of allergens onto lens

AKC (Bielory)

Ocular contact dermatitis

• Avoidance of the offending agent(s)
• Comfort measures that can be taken include cool compresses four to six times a day, avoidance of hot water and soaps
• Application of a mild steroid cream over the affected area
• Topical antihistamines and steroid drops may be indicated

Dry Eye Treatment

• Frequent blinking, artificial tears QID is 1st line treatment
  • Use preservative free artificial tears if hypersensitivity to preservatives is suspected)
• Restasis (topical cyclosporine 0.05%) is effective for some patients but an ophthalmology evaluation should be done first

References